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Phu VD, Nadjm B, Duy NHA, Co DX, Mai NTH, Trinh DT, Campbell J, Khiem DP, Quang TN, Loan HT, Binh HS, Dinh QD, Thuy DB, Lan HNP, Ha NH, Bonell A, Larsson M, Hoan HM, Tuan ĐQ, Hanberger H, Minh HNV, Yen LM, Van Hao N, Binh NG, Chau NVV, Van Kinh N, Thwaites GE, Wertheim HF, van Doorn HR, Thwaites CL. Ventilator-associated respiratory infection in a resource-restricted setting: impact and etiology. J Intensive Care 2017; 5:69. [PMID: 29276607 PMCID: PMC5738227 DOI: 10.1186/s40560-017-0266-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 11/27/2017] [Indexed: 01/16/2023] Open
Abstract
Background Ventilator-associated respiratory infection (VARI) is a significant problem in resource-restricted intensive care units (ICUs), but differences in casemix and etiology means VARI in resource-restricted ICUs may be different from that found in resource-rich units. Data from these settings are vital to plan preventative interventions and assess their cost-effectiveness, but few are available. Methods We conducted a prospective observational study in four Vietnamese ICUs to assess the incidence and impact of VARI. Patients ≥ 16 years old and expected to be mechanically ventilated > 48 h were enrolled in the study and followed daily for 28 days following ICU admission. Results Four hundred fifty eligible patients were enrolled over 24 months, and after exclusions, 374 patients’ data were analyzed. A total of 92/374 cases of VARI (21.7/1000 ventilator days) were diagnosed; 37 (9.9%) of these met ventilator-associated pneumonia (VAP) criteria (8.7/1000 ventilator days). Patients with any VARI, VAP, or VARI without VAP experienced increased hospital and ICU stay, ICU cost, and antibiotic use (p < 0.01 for all). This was also true for all VARI (p < 0.01 for all) with/without tetanus. There was no increased risk of in-hospital death in patients with VARI compared to those without (VAP HR 1.58, 95% CI 0.75–3.33, p = 0.23; VARI without VAP HR 0.40, 95% CI 0.14–1.17, p = 0.09). In patients with positive endotracheal aspirate cultures, most VARI was caused by Gram-negative organisms; the most frequent were Acinetobacter baumannii (32/73, 43.8%) Klebsiella pneumoniae (26/73, 35.6%), and Pseudomonas aeruginosa (24/73, 32.9%). 40/68 (58.8%) patients with positive cultures for these had carbapenem-resistant isolates. Patients with carbapenem-resistant VARI had significantly greater ICU costs than patients with carbapenem-susceptible isolates (6053 USD (IQR 3806–7824) vs 3131 USD (IQR 2108–7551), p = 0.04) and after correction for adequacy of initial antibiotics and APACHE II score, showed a trend towards increased risk of in-hospital death (HR 2.82, 95% CI 0.75–6.75, p = 0.15). Conclusions VARI in a resource-restricted setting has limited impact on mortality, but shows significant association with increased patient costs, length of stay, and antibiotic use, particularly when caused by carbapenem-resistant bacteria. Evidence-based interventions to reduce VARI in these settings are urgently needed. Electronic supplementary material The online version of this article (10.1186/s40560-017-0266-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Vu Dinh Phu
- National Hospital for Tropical Diseases, Hanoi, Vietnam.,Oxford University Clinical Research Unit, Hanoi, Vietnam
| | - Behzad Nadjm
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | | | | | - Nguyen Thi Hoang Mai
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - James Campbell
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | | | - Huynh Thi Loan
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | | | - Quynh-Dao Dinh
- Oxford University Clinical Research Unit, Hanoi, Vietnam
| | - Duong Bich Thuy
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Huong Nguyen Phu Lan
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Ana Bonell
- Oxford University Clinical Research Unit, Hanoi, Vietnam
| | | | | | | | | | | | - Lam Minh Yen
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Nguyen Van Hao
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam.,University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | | | | | | | - Guy E Thwaites
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Heiman F Wertheim
- Department of Medical Microbiology and Radboud Center for Infectious Diseases, Radboudumc, Nijmegen, Netherlands
| | - H Rogier van Doorn
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - C Louise Thwaites
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
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Phu VD, Wertheim HFL, Larsson M, Nadjm B, Dinh QD, Nilsson LE, Rydell U, Le TTD, Trinh SH, Pham HM, Tran CT, Doan HTH, Tran NT, Le ND, Huynh NV, Tran TP, Tran BD, Nguyen ST, Pham TTN, Dang TQ, Nguyen CVV, Lam YM, Thwaites G, Van Nguyen K, Hanberger H. Burden of Hospital Acquired Infections and Antimicrobial Use in Vietnamese Adult Intensive Care Units. PLoS One 2016; 11:e0147544. [PMID: 26824228 PMCID: PMC4732823 DOI: 10.1371/journal.pone.0147544] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 01/04/2016] [Indexed: 12/29/2022] Open
Abstract
Background Vietnam is a lower middle-income country with no national surveillance system for hospital-acquired infections (HAIs). We assessed the prevalence of hospital-acquired infections and antimicrobial use in adult intensive care units (ICUs) across Vietnam. Methods Monthly repeated point prevalence surveys were systematically conducted to assess HAI prevalence and antimicrobial use in 15 adult ICUs across Vietnam. Adults admitted to participating ICUs before 08:00 a.m. on the survey day were included. Results Among 3287 patients enrolled, the HAI prevalence was 29.5% (965/3266 patients, 21 missing). Pneumonia accounted for 79.4% (804/1012) of HAIs Most HAIs (84.5% [855/1012]) were acquired in the survey hospital with 42.5% (363/855) acquired prior to ICU admission and 57.5% (492/855) developed during ICU admission. In multivariate analysis, the strongest risk factors for HAI acquired in ICU were: intubation (OR 2.76), urinary catheter (OR 2.12), no involvement of a family member in patient care (OR 1.94), and surgery after admission (OR 1.66). 726 bacterial isolates were cultured from 622/1012 HAIs, most frequently Acinetobacter baumannii (177/726 [24.4%]), Pseudomonas aeruginosa (100/726 [13.8%]), and Klebsiella pneumoniae (84/726 [11.6%]), with carbapenem resistance rates of 89.2%, 55.7%, and 14.9% respectively. Antimicrobials were prescribed for 84.8% (2787/3287) patients, with 73.7% of patients receiving two or more. The most common antimicrobial groups were third generation cephalosporins, fluoroquinolones, and carbapenems (20.1%, 19.4%, and 14.1% of total antimicrobials, respectively). Conclusion A high prevalence of HAIs was observed, mainly caused by Gram-negative bacteria with high carbapenem resistance rates. This in combination with a high rate of antimicrobial use illustrates the urgent need to improve rational antimicrobial use and infection control efforts.
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Affiliation(s)
- Vu Dinh Phu
- Intensive Care Unit, National Hospital for Tropical Diseases, Ha Noi, Vietnam
| | - Heiman F L Wertheim
- Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Hanoi, Vietnam.,Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom
| | - Mattias Larsson
- Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden
| | - Behzad Nadjm
- Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Hanoi, Vietnam.,Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom
| | - Quynh-Dao Dinh
- Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Hanoi, Vietnam
| | - Lennart E Nilsson
- Clinical Microbiology, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Ulf Rydell
- Infectious Diseases, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | | | | | | | | | - Hanh Thi Hong Doan
- Board of Directors, Vietnam-Sweden Uong Bi Hospital, Quang Ninh, Vietnam
| | - Nguyen Thua Tran
- Department of General Internal Medicine & Geriatric, Hue Central General Hospital, Hue, Vietnam
| | - Nhan Duc Le
- Board of Directors, Da Nang Hospital, Da Nang, Vietnam
| | - Nhuan Van Huynh
- Infectious Department, Binh Dinh Hospital, Binh Dinh, Vietnam
| | | | - Bao Duc Tran
- Planning Department, Dak Lak Hospital, Dak Lak, Vietnam
| | | | | | - Tam Quang Dang
- Board of Directors, Can Tho Central General Hosptial, Can Tho, Vietnam
| | | | - Yen Minh Lam
- Board of directors, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Guy Thwaites
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom.,Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Kinh Van Nguyen
- Board of Directors, National Hospital for Tropical Diseases, Ha Noi, Vietnam
| | - Hakan Hanberger
- Infectious Diseases, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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Van TD, Dinh QD, Vu PD, Nguyen TV, Pham CV, Dao TT, Phung CD, Hoang HTT, Tang NT, Do NT, Nguyen KV, Wertheim H. Antibiotic susceptibility and molecular epidemiology of Acinetobacter calcoaceticus-baumannii complex strains isolated from a referral hospital in northern Vietnam. J Glob Antimicrob Resist 2014; 2:318-321. [PMID: 25540720 PMCID: PMC4270437 DOI: 10.1016/j.jgar.2014.05.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 03/12/2014] [Accepted: 05/15/2014] [Indexed: 10/28/2022] Open
Abstract
Acinetobacter calcoaceticus-baumannii complex is a common cause of hospital-acquired infections (HAIs) globally, remarkable for its high rate of antibiotic resistance, including to carbapenems. There are few data on the resistance of A. baumannii in Vietnam, which are essential for developing evidence-based treatment guidelines for HAIs. Antibiotic susceptibility testing was conducted by VITEK®2, and pulsed-field gel electrophoresis (PFGE) was performed on 66 clinical A. baumannii complex isolates recovered during 2009 at the National Hospital of Tropical Diseases (NHTD), a referral hospital in Hanoi, Vietnam. Basic demographic and clinical data were collected and analysed using descriptive statistics. Most isolates came from lower respiratory tract specimens (59; 89.4%) from intensive care unit (ICU) patients [64/65 (98.5%) with available data] who had been admitted to NHTD for ≥2 days [42/46 (91.3%) with available data]. More than 90% of the isolates were resistant to the tested β-lactamase/β-lactamase inhibitors, cephalosporins, carbapenems, fluoroquinolones and trimethoprim/sulfamethoxazole. Moreover, 25.4% (16/63) were resistant to all tested β-lactams, quinolones and aminoglycosides. All isolates remained sensitive to colistin and 58.7% were susceptible to tigecycline. Of the 66 isolates, 49 could be classified into eight PFGE types (A-H). Every PFGE type, except D, had cluster(s) of three or more isolates with a temporal relationship. In conclusion, these data suggest a significant rise in A. baumannii antibiotic resistance in Vietnam. Clustering within PFGE types supports cross-transmission of A. baumannii within the ICU at NHTD. Increased research and resources in optimising treatment, infection control and antibiotic stewardship are needed.
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Affiliation(s)
| | - Quynh-Dao Dinh
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Program, Hanoi, Viet Nam
| | - Phu Dinh Vu
- National Hospital of Tropical Diseases, Hanoi, Viet Nam
| | | | - Ca Van Pham
- National Hospital of Tropical Diseases, Hanoi, Viet Nam
| | | | - Cam Dac Phung
- National Institute of Hygiene and Epidemiology, Hanoi, Viet Nam
| | | | - Nga Thi Tang
- National Institute of Hygiene and Epidemiology, Hanoi, Viet Nam
| | - Nga Thuy Do
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Program, Hanoi, Viet Nam
| | | | - Heiman Wertheim
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Program, Hanoi, Viet Nam ; Nuffield Department of Clinical Medicine, Centre for Tropical Medicine, University of Oxford, Oxford, UK
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Spencer C, Pajovic S, Devlin H, Dinh QD, Corson TW, Gallie BL. Distinct patterns of expression of the RB gene family in mouse and human retina. Gene Expr Patterns 2005; 5:687-94. [PMID: 15939381 DOI: 10.1016/j.modgep.2005.02.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2004] [Accepted: 02/07/2005] [Indexed: 11/25/2022]
Abstract
Although RB1 function is disrupted in the majority of human cancers, an undefined cell of developing human retina is uniquely sensitive to cancer induction when the RB1 tumor suppressor gene is lost. Murine retinoblastoma is initiated only when two of the RB family of genes, RB1 and p107 or p130, are inactivated. Although whole embryonic retina shows RB family gene expression by several techniques, when E14 developing retina was depleted of the earliest differentiating cells, ganglion cells, the remaining proliferating murine embryonic retinal progenitor cells clearly did not express RB1 or p130, while the longer splice form of p107 was expressed. Each retinal cell type expressed some member of the RB family at some stage of differentiation. Rod photoreceptors stained for the RB1 protein product, pRB, and p107 in only a brief window of postnatal murine development, with no detectable staining for any of the RB family proteins in adult human and mouse rod photoreceptors. Adult mouse and human Muller glia, ganglion and rare horizontal cells, and adult human, but not adult mouse, cone photoreceptors stained for pRB. The RB gene family is dynamically and variably expressed through retinal development in specific retinal cells.
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Affiliation(s)
- Clarellen Spencer
- The Division of Cancer Informatics, Ontario Cancer Institute/Princess Margaret Hospital, University Health Network, Toronto, Canada
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